Healthcare Provider Details

I. General information

NPI: 1245146596
Provider Name (Legal Business Name): MACKENZIE IVERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MACKENZIE KAISER RN

II. Dates (important events)

Enumeration Date: 08/19/2026
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 LASALLE AVE STE 2800
MINNEAPOLIS MN
55402-2039
US

IV. Provider business mailing address

19734 YORK ST NW
ELK RIVER MN
55330-8231
US

V. Phone/Fax

Practice location:
  • Phone: 612-349-8560
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code209800000X
TaxonomyLegal Medicine (M.D./D.O.) Physician
License Number2458837
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: